Book Report: Medical memoir tells stories of resilience among poor

Portlander Patricia Kullberg's new book "On the Ragged Edge of Medicine, Doctoring Among the Dispossessed" ($18.95, Oregon State University Press) is a medical memoir, with wrenching stories of her time on the front lines treating society's poorest people at the Burnside Health Center.

Kullberg spent 20 years as medical director of the Multnomah County Health Department. This intimate and poignant portrayal is about the resilient people she met working among Portland's most disenfranchised. Kullberg's previous book is "Girl in the River."

"The Ragged Edge" is something she has been working on for many years. The Tribune caught up with Kullberg to discuss:

Tribune: Tell us a bit about why you structured the book how you did, in 15 vignettes.

Kullberg: I think that telling stories is the most effective way to investigate, explore and reveal the implications or the problems in medicine or any field. It fixes something in a reader's mind and it helps the reader grasp the issues better. The stories that I picked were almost exclusively about relationships that had not gone as planned. The book is really about failure — failure of society and of the medical field. How I failed, and how patients fail, and asking, how do they overcome it and cope with it? It was born out of my interest in looking at that.

Tribune: What initially drew you to community medicine?

Kullberg: I'm a child of the '60s. I always had this idea that I wanted to go into medicine. I had a skill and a knowledge and I wanted to employ that where it could do the most good, and the need was the greatest. And I wanted an intellectual and a personal challenge. My first job was one that served a middle class population and I got bored rather quickly. And I tell you I was never bored here. It was a very rewarding practice. I think my initial motivation probably involved some kind of maternalism or paternalism. It was a desire to do a kind of "medical slumming" but I very quickly was disabused of those notions. I found the people so engaging. They have the same fears and desires and make the same kinds of mistakes as the rest of us. They just suffer so much more for those mistakes.

Tribune: Why did you write this book?

Kullberg: I wrote the book initially for myself, because when things went sour I really needed to come to terms with that. Sometimes there were issues that I felt I had contributed to. And when you start writing down what happened it forces a kind of clarity about what did happen and why — and it lets you dig deeper into the story or the narrative. And I wrote it to come to terms with various issues and to forgive myself for the mistakes I made. I also wanted to bear witness and to draw the curtain back. And to validate the work that's done because most people have no idea.

Tribune: I was struck by the will to live when it would be far easier to give up.

Kullberg: There is incredible resilience in that population. I was just appalled to hear about their circumstances, and how they even could get up in the morning and press forward.

Tribune: This winter four homeless people died on Portland streets. In your opinion, what can our city do?

Kullberg: There is a movement, or a concept, of housing first. It's a very rational idea. Because treating pneumonia, diabetes or an infection isn't very helpful if they're living on the streets. There have been health care models that take people off the street and put them in housing. This in turn can be a cost saving measure. Shelters are not cheap, and the demands on the healthcare system cost a lot, too. So if you can avoid all that, it's better to house people first.

Tribune: One day you see a patient named Lawrence when you aren't scheduled to see patients, and you play hooky from the paperwork to go through his meds and then just talk together. You write, "Here was the unalloyed pleasure of clinical medicine, the privilege I treasured most, to listen to people tell stories. It was a privilege I rarely enjoyed."

Kullberg: The time pressure is extreme and it's really a false economy — when I look back at that particular case I see how much time was wasted. Some of it is how we choose to spend the minutes, but we can't blow off what we are supposed to do. But there is a growing movement around storytelling, it requires an investment up front, but there are efficiencies to be gained from doing that. Knowing who your patients are in a more personal way I think cements the relationships and helps you make better plans. The health department at one point had a very, very complex set of funding sources, so you'd have many different masters. The recording requirements were all different, and the bureaucratic overhead was very wasteful.

Tribune: How did you keep from being overwhelmed by the suffering? What was your outlet at the end of the day?

Kullberg: The writing certainly helped. But in fact I didn't cope very well, it was hard. My husband and son suffered a bit of neglect. Emotionally I was not in great shape when I came home at night. I was too busy trying to calm myself down. I tried to pay attention to sleep, exercises and diet. Talking to friends and support from colleagues was absolutely critical. Being in a team was very important, knowing you weren't in it alone. You kind of muddle along. Some people are better at brushing it off than others. Medicine is a tough field and the suicide rate is very high in all kinds of medical practices.

Tribune: Do caring people continue to enter this particular area of medicine?

Kullberg: I hope so. We had a very politicized generation come out of the '60s. And I think we're entering a time when people are being politicized and asking how they can contribute rather than just how they can have just a good life. I see an upswing of activism and I think that will spill over to medicine. Over the years we've gotten better at tackling complex problems — it's vastly better now — we've gotten much more sophisticated and we've been given better resources. The Affordable Care Act with all its problems has helped so much. If we roll that back, the way they are talking of doing in D.C., that could change, but I think the will and the knowledge will still be there.